Water or antiseptic for periurethral cleaning before urinary catheterization: a randomized controlled trial

BACKGROUND

Despite a lack of empiric data to support the practice, traditionally, antiseptic solutions have been used to clean the periurethral area before inserting an indwelling catheter. The purpose of this study was to compare urinary colonization rates of subjects whose periurethral area was cleaned with water versus chlorhexidine 0.1% before the insertion of an indwelling urinary catheter.

METHODS

Obstetric patients who required urinary catheterization as part of their routine care were randomly assigned to either the "water" or "chlorhexidine" group with a sealed envelope. A sterile specimen of urine was collected 24 hours after insertion of the catheter.

RESULTS

Of the 436 patients (86.2%) with complete data (water group, 219; antiseptic group, 217), 38 (8.7%) had urinary tract bacteriuria >10(6) cfu/L. Rates of urinary tract infection were similar in each group (water group, 8.2%; antiseptic group, 9.2%; odds ratio 1.13; 95% confidence interval 0.58-2.21).

CONCLUSION

The practice of periurethral cleaning with an antiseptic did not decrease the rates of bacteriuria in this population and is probably not useful.

The origin and spread of the new daisy rust in Britain

Since 1997, wild and cultivated daisies in Britain and other European countries have been suffering from a rust fungus epidemic that menaces the future cultivation of horticultural varieties. The causal fungus was first discovered in Australia 100 years ago and may have evolved there from another rust fungus on daisies previously introduced from Europe. At present, ornamental daisies can be grown successfully only when protected by fungicide sprays.

An investigation of the interaction between thematic and phrasal structure in nonfluent agrammatic subjects

Garrett (1982) developed a model of normal sentence production which has been used in the description of aphasic language (Schwartz, 1987). This study investigated the effects of the thematic representation specified at the functional level on the complexity of the phrases produced at the positional level. A group of 14 nonfluent, agrammatic subjects were compared to 20 normal controls in their production of the story of Cinderella. The agrammatic subjects produced fewer argument structures than the normal control subjects. Their phrasal realization of the arguments, however, was not qualitatively different from that of the normal subjects. In both cases, with an increase in the number of arguments, there was a concurrent increase in the mean complexity of the phrases used to realize those arguments and in the total phrasal complexity of the utterances. The complexity of noun phrases differed according to the thematic roles expressed; this seemed to be a consequence of their different locations in the sentence. Preverbal noun phrases were much less complex than postverbal noun phrases. There was no evidence to suggest that there was a trade-off between the production of thematic structure and subsequent phrasal production. Neither was there evidence to suggest that production differed according to whether the phrase was an argument of the verb or a nonargument. The complexity of a phrase was determined by the type of information it conveyed.

Tryptase-positive mast cells accompany lymphocytic as well as lymphoplasmacytic lymphoma infiltrates in bone marrow trephine biopsies

AIMS

To investigate the specificity of increased bone marrow mast cell numbers in lymphoplasmacytic lymphoma (LPL) and to evaluate the relationship between mast cell number and the immunoglobulin phenotype of neoplastic lymphoid cells.

METHODS AND RESULTS

Retrospective study of bone marrow trephine biopsy specimens from patients with LPL, compared with selected cases representing chronic lymphocytic leukaemia (CLL) and multiple myeloma (MM) of known immunoglobulin light and heavy chain phenotype. Bone marrow mast cells were counted following immunohistochemical staining of sections for mast cell tryptase. We have confirmed previous observations that mast cell numbers are increased in bone marrow infiltrates of LPL. However, we found similarly high mast cell numbers in CLL. High mast cell numbers were associated with neoplastic lymphoid cells expressing an IgM kappa phenotype. Mast cell numbers were low in all cases of MM studied and in controls with no lymphoma present. We observed an apparent bias towards kappa light chain expression in our cases of LPL.

CONCLUSIONS

Mast cell number should not be considered a reliable factor in the differential diagnosis of LPL and CLL when assessing bone marrow histology. Possible bias towards kappa light chain expression in LPL requires further study, as do the mechanism and functions of mast cell recruitment by neoplastic lymphoid cells.

Virus-neutralizing monoclonal antibody expressed in milk of transgenic mice provides full protection against virus-induced encephalitis

Neutralizing antibodies represent a major host defense mechanism against viral infections. In mammals, passive immunity is provided by neutralizing antibodies passed to the offspring via the placenta or the milk as immunoglobulin G and secreted immunoglobulin A. With the long-term goal of producing virus-resistant livestock, we have generated mice carrying transgenes that encode the light and heavy chains of an antibody that is able to neutralize the neurotropic JHM strain of murine hepatitis virus (MHV-JHM). MHV-JHM causes acute encephalitis and acute and chronic demyelination in susceptible strains of mice and rats. Transgene expression was targeted to the lactating mammary gland by using the ovine beta-lactoglobulin promoter. Milk from these transgenic mice contained up to 0.7 mg of recombinant antibody/ml. In vitro analysis of milk derived from different transgenic lines revealed a linear correlation between antibody expression and virus-neutralizing activity, indicating that the recombinant antibody is the major determinant of MHV-JHM neutralization in murine milk. Offspring of transgenic and control mice were challenged with a lethal dose of MHV-JHM. Litters suckling nontransgenic dams succumbed to fatal encephalitis, whereas litters suckling transgenic dams were fully protected against challenge, irrespective of whether they were transgenic. This demonstrates that a single neutralizing antibody expressed in the milk of transgenic mice is sufficient to completely protect suckling offspring against MHV-JHM-induced encephalitis.

Insulin-like growth factor binding protein-5 (IGFBP-5) potentially regulates programmed cell death and plasminogen activation in the mammary gland

This study aims to investigate the mechanism by which prolactin and GH interact to maintain mammary epithelial cell function in the rat. IGF-I is an important survival factor for the mammary gland and we have demonstrated that the effects of GH and prolactin involve IGF-I. GH acts by increasing IGF-I whilst prolactin acts by inhibiting the expression of IGFBP-5 from the mammary epithelium. During mammary involution, when serum prolactin levels decline, IGFBP-5 expression is dramatically upregulated and it binds with high affinity to IGF-I preventing IGF-I interaction with the IGF-receptor and thus leading to epithelial cell apoptosis. We have identified a specific interaction of IGFBP-5 with alpha s2-casein. This milk protein has also been shown to bind plasminogen and its activator tissue-type plasminogen activator (tPA) leading to enhanced conversion of plasminogen to plasmin. Plasmin is an important initiator of re-modelling of the extracellular matrix during mammary involution. A potential interaction between the cell death and extracellular matrix remodelling is evident from the observation that IGFBP-5 binds to plasminogen activator inhibitor-I (PAI-1). We thus hypothesized that IGFBP-5 could activate cell death by sequestration of IGF-I and activate plasminogen cleavage by sequestering PAI-1. In support of this hypothesis we have shown that both prolactin and GH inhibit tPA activity and plasminogen activation in the involuting mammary gland. Our results suggest that GH and prolactin inhibit cell death and ECM remodelling via the IGF-axis and also indicate a novel role for the milk protein alpha s2-casein in this process. We have now established lines of transgenic mice expressing IGFBP-5 on the beta-lactoglobulin promoter to explore its function in greater detail.

Characteristics of sustained blood-brain barrier opening and tissue injury in a model for focal trauma in the rat

Minor stab wounding of rodent brain by needle or razor blade is a standard model for immunohistochemical investigations of secondary neuronal degeneration and scarring. Opening of the blood-brain barrier (BBB) to plasma molecules and inflammatory cells is integral to the secondary injury process. To facilitate quantitative study of these BBB phenomena, we tested the utility of a stereotaxic wire knife as a minimally invasive way for modeling of focal trauma and bleeding in brain parenchyma and substantial, reproducible BBB damage. Adult rats were anesthetized, and through a skull burr hole, the 0.3-mm dia guide cannula housing a laterally extendable tungsten wire (0.13 mm dia) was inserted into the right striatum. A layering of horizontal disk-like cuts (3 mm dia) was made, producing a cylindrical lesion of approximately 18 mm3 volume, approximately 2.7% of the cerebral hemisphere. Transfer constants (Ki) for blood to brain permeation of [3H]sucrose measured from 30 min to 2 weeks postlesion showed sustained BBB leakiness; for example, mean Ki +/- SEM (nL.g(-1) x s(-1)) for a standard, matrix-dissected forebrain sample enclosing the lesion were 7.2 +/- 1.2 (day 1 postlesion), 8.1 +/-1.4 (day 3), 5.4 +/- 0.8 (day 14) compared with values for contralateral nonlesioned forebrain ranging from 1.3 +/- 0.05 to 1.6 +/- 0.3 (n = 3-4 samples per time point). Analysis of the simultaneous transport of [14C]sucrose (MW = 342 Da) and [3H]inulin (MW approximately 5,000) showed significantly larger upward increments in Ki for sucrose than inulin, indicating a pore-like opening mechanism. Significant edema was measured 3 days postlesion. A reactive glial response was indicated by an increase in S100beta by 6 h and a glial scar forming around the lesion by 7 days. Secondary brain injury was indicated by a 10% loss of hemisphere mass, measured at 2 months. The wire knife enabled tailoring of interstitial trauma with a minimum of extraneous injury and supported reproducible measurements of sustained BBB injury using relatively few animals.

Are There Benefits for Patients Attending ‘A Heart Failure Clinic'? A Five Year Review

Objective

To determine the effects of attendance at a chronic ‘heart failure clinic', with emphasis on patient education on morbidity, hospitalisations and mortality associated with heart failure due to left ventricular systolic dysfunction.

Design

Retrospective case audit study.

Setting

University hospital with a primary catchment area of 500,000 inhabitants.

Patients

100 patients (aged 54–87 years, 59% male) with a confirmed diagnosis of left ventricular systolic dysfunction.

Methods

Patients regularly reviewed at a ‘heart failure clinic’ where emphasis was placed on optimisation of drug therapy, patient education, self-management, and adherence to treatment regimes.

Results

The median age of the study population was 72 (50–87 years), 89% had a current NYHA status of III/IV. The average dose of frusemide was 111mg/day, with 74% of the study group receiving an ACE inhibitor and 15% an angiotensin II antagonist or vasodilator. Hospitalisation rate was 0.7±0.1 admissions per patient per year, the length of stay during admission was 11.8±2 days (females) and 10.5±2.2 days (males), and the average length of survival from first clinic attendance was 5.3±1.75 years for females and 2.97±0.5 years for males.

Conclusions

Attendance at a ‘heart failure clinic’ ensures optimisation of medication, reduction of patient admission rate and duration of hospitalisation.

Prediction of functional outcome and in-hospital mortality after admission with oral anticoagulant-related intracerebral hemorrhage

BACKGROUND AND PURPOSE

Early survival of patients with intracerebral hemorrhage in general is known to be most strongly dependent on the Glasgow Coma Scale score on admission. The aim of this study was to examine the factors determining functional outcome and in-hospital mortality of patients admitted with an intracerebral hemorrhage related to oral anticoagulant (OAC) use.

METHODS

Correlation studies and multiple logistic regression analyses were performed on data from a retrospective series of 42 patients admitted with OAC-related intracerebral hemorrhages over a 6-year period to a tertiary care center in the north of Scotland.

RESULTS

The functional outcome after an OAC-related intracerebral hemorrhage was dependent on maximum diameter of hematoma on CT scan (R:=-0.72, P:<0. 001) and international normalized ratio (INR) (R:=-0.35, P:=0.024). Hematoma diameter and INR were not themselves strongly correlated (R:=0.31, P:=0.099). In-hospital mortality can be predicted by the Glasgow Coma Scale score alone (R:(2)=0.36, overall predictive accuracy 68%) but more accurately by a logistic regression model including hematoma diameter and CT signs of cerebrovascular disease (R:(2)=0.70, predictive accuracy 83%).

CONCLUSIONS

Neither functional outcome nor in-hospital mortality appears to be strongly dependent on INR measured on admission. CT scan, however, provides essential information and allows accurate predictions about the short-term outcome of OAC-related intracerebral hemorrhages.

Improving antenatal recognition of women at risk for postnatal depression

The purpose of this study was to assess the effectiveness of a practical antenatal screen used at the Royal Women's Hospital, Brisbane, to identify women at risk for postnatal depression. It was a prospective, hospital-based, cohort study of 901 women (600 with and 301 without prenatal risk factors for postnatal depression). Depression was measured 16 weeks after the birth using the Edinburgh Postnatal Depression Scale. More of the women with a prenatal risk factor for depression (25.9%) scored above 12 on the Edinburgh Postnatal Depression Scale than those without any risk (10.9%) (p < or = 0.001). Low social support (p < or = 0.001), a personal history of mood disorder (p < or = 0.001) and a past history of postnatal depression ( p = 0.002) were all strongly associated with postnatal depression in this sample. Results indicate that an objective, psychosocial assessment during pregnancy improves recognition of women at risk for postnatal depression.

Response to antihypertensive therapy in older patients with sustained and nonsustained systolic hypertension. Systolic Hypertension in Europe (Syst-Eur) Trial Investigators

BACKGROUND

The goal of the present study was to assess the effect of antihypertensive therapy on clinic (CBP) and ambulatory (ABP) blood pressures, on ECG voltages, and on the incidence of stroke and cardiovascular events in older patients with sustained and nonsustained systolic hypertension.

METHODS AND RESULTS

Patients who were >/=60 years old, with systolic CBP of 160 to 219 mm Hg and diastolic CBP of <95 mm Hg, were randomized into the double-blind placebo-controlled Systolic Hypertension in Europe (Syst-Eur) Trial. Treatment consisted of nitrendipine, with the possible addition of enalapril, hydrochlorothiazide, or both. Patients enrolled in the Ambulatory Blood Pressure Monitoring Side Project were classified according to daytime systolic ABP into 1 of 3 subgroups: nonsustained hypertension (<140 mm Hg), mild sustained hypertension (140 to 159 mm Hg), and moderate sustained hypertension (>/=160 mm Hg). At baseline, patients with nonsustained hypertension had smaller ECG voltages (P<0.001) and, during follow-up, a lower incidence of stroke (P<0.05) and of cardiovascular complications (P=0.01) than other groups. Active treatment reduced ABP and CBP in patients with sustained hypertension but only CBP in patients with nonsustained hypertension (P<0.001). The influence of active treatment on ECG voltages (P<0.05) and on the incidence of stroke (P<0.05) and cardiovascular events (P=0.06) was more favorable than that of placebo only in patients with moderate sustained hypertension.

CONCLUSIONS

Patients with sustained hypertension had higher ECG voltages and rates of cardiovascular complications than did patients with nonsustained hypertension. The favorable effects of active treatment on these outcomes were only statistically significant in patients with moderate sustained hypertension.

Analysis of risk factors involved in oral-anticoagulant-related intracranial haemorrhages

We examined risk factors for intracranial bleeding while on oral anticoagulants (OACs) in 68 patients admitted to hospital over a 6-year period, and 204 out-patient controls followed-up in an OAC clinic. Under multivariate analysis, significant risk factors for OAC-related intracranial bleeds were hypertension (OR (95%CI) 2.69 (1.04-6.97), duration of OAC therapy < or =12 months (OR 3.74 (1.21-11.56)), duration > or =96 months (OR 0.25 (0.07-0.88)), and International Normalized Ratio on admission >4.5 (OR 10.92 (2.46-48.43)). A logistic regression model including the above variables along with a history of 'cerebrovascular disease' (OR 2.32 (0.98-5.46)) correctly predicted intracranial bleeding (or its absence) during OAC therapy in 85% of all patients. The risk associated with advanced age and concomitant aspirin use was not significantly increased in this analysis. It is important to achieve tight control of INR, particularly in the early months of treatment. Patients with previous cerebrovascular disease are at increased risk of intracranial bleeding on warfarin, and hypertensive patients should have especially close monitoring and optimal control of their blood pressure.

Course, management and outcome of oral-anticoagulant-related intracranial haemorrhages

The aim of this study was to compare the clinical course and radiological features of oral anticoagulant (OAC)-related intracranial haemorrhages with those of haemorrhages unrelated to OAC use admitted over the last six years to a tertiary care centre in the North of Scotland. We furthermore wished to determine the measures taken for reversal of OAC therapy and the resulting short-term outcome. Sixty-eight patients had been treated with OACs at the time of intracranial haemorrhage (32% subdural, 62% intracerebral). Patients admitted with OAC-related and unrelated haemorrhages did not differ significantly in any of the clinical features considered. On CT scan, there was no significant difference according to OAC use in the mean size of subdural (depth 15 +/- 5 vs. 18 +/- 8 mm, p = 0.36), or intracerebral haematomas (max. diameter 40 +/- 21 vs. 41 +/- 20 mm, p = 0.73). No reversal measures were taken in 38% of OAC-treated patients. In-hospital mortality was significantly higher for OAC-related haemorrhages compared to unrelated haemorrhages (38% vs. 18%, p = 0.001). To further elucidate the effects of anticoagulant reversal on the outcome of OAC-related intracranial haemorrhages, a large-scale prospective study is warranted.

Intracerebral haemorrhages and oral anticoagulation in the north of Scotland

The aim of this study has been twofold: 1--to examine the impact of oral anticoagulant (OAC) use on a possible recent rise in the admission rate of intracerebral haemorrhages to Aberdeen Royal Infirmary (ARI), and 2--to estimate the absolute risk of intracranial haemorrhage for outpatients followed up in the OAC Clinic at ARI. The number of patients admitted to ARI with intracerebral bleedings increased by 60% between 1993 and 1998. A corresponding increase in the proportion of patients with concurrent OAC use (4.7% vs 15.7%, p = 0.055) cannot sufficiently explain the increase in the total number of intracerebral haemorrhages. The average annual incidence of intracranial haemorrhages for the OAC Clinic at ARI is found to be acceptably low at 0.33% per year. Further audit of the large number of patients receiving warfarin outwith the supervision of the clinic is urgently required.

Maintaining study validity in a changing clinical environment

BACKGROUND

Nurse scientists who conduct intervention research in a variety of clinical settings find themselves facing numerous challenges posed by today's changing and sometimes complex health care environment. Maintaining study validity thus becomes a major focus of interventional research, but existing literature does not fully address challenges to study validity nor offer potential solutions.

OBJECTIVES

The purposes of this paper are to 1) discuss methodologic challenges to maintaining study validity of intervention research that is conducted in a changing clinical environment, and 2) share strategies for maximizing study validity.

METHODS

A recently completed intervention study is used as an example to discuss two specific areas that affected study validity, provide examples of selected threats to validity, and outline strategies used to minimize these threats.

RESULTS

Careful definition of goals, thoughtful decision making, and implementation of specific strategies to maintain study validity helped increased the rigor of the research.

CONCLUSIONS

Investigators conducting intervention research in changing clinical settings can reduce threats to study validity and increase design rigor by considering clinical realities (e.g., clinician-researcher role conflict) when making methodologic decisions, becoming familiar with the setting, and involving clinicians in the research.

A comparison of two approaches in the treatment of perceptual problems after stroke

OBJECTIVE

To compare the effectiveness of the transfer of training and functional approaches in improving perceptual and functional abilities after stroke.

DESIGN

Patients identified as having perceptual problems were randomly allocated to either the transfer of training approach or the functional approach for perceptual treatment. On completion of six weeks of treatment, each patient was reassessed for perceptual and functional abilities.

SUBJECTS AND SETTING

Eighty inpatients on the Nottingham Stroke Unit.

INTERVENTIONS

Perceptual treatment was given for 2.5 hours per week for six weeks.

MAIN OUTCOME MEASURES

Rivermead Perceptual Assessment Battery, Barthel ADL Index and Edmans ADL index.

RESULTS

There was no significant difference between the treatment groups on patient characteristics or impairments. The results also showed no significant difference between the treatment groups before and after treatment on perceptual ability total scores, individual perceptual subtest scores, or functional ability total scores (Mann-Whitney U 642.5-798.0, p > 0.05). Wilcoxon matched pairs signed ranks tests showed a significant improvement in both groups after treatment on perceptual and functional abilities (perceptual z = 6.02, p < 0.001, functional z = 6.72, p < 0.001).

CONCLUSIONS

These results indicated that the improvement in perceptual abilities was equivalent using either of the two approaches. This could be due to spontaneous recovery or the effects of the Stroke Unit.

Measuring social support in pregnancy: can it be simple and meaningful?

BACKGROUND

It is important to determine the level of a woman's social support at the booking-in interview for prenatal care, but measurement tends to be ad hoc and nonquantifiable. The purpose of this study was to describe the Maternity Social Support Scale and the relationship between support scale ratings and the Edinburgh Postnatal Depression Scale and other health and service use outcomes.

METHODS

Women (n = 901) who attended the antenatal clinic at the Royal Women's Hospital in Brisbane, Australia, were asked to complete a support scale as part of their booking-in interview. Participants were contacted at 16 weeks postpartum and invited to complete a follow-up questionnaire. Relationships between the scale and study outcomes were explored using analysis of variance and chi-square tests.

RESULTS

Women with low social support in pregnancy were more likely than well-supported women to report poorer health during pregnancy (p = 0.006) and postnatally (p < 0.001), to book later for prenatal care (p = 0.000), to seek medical help more frequently (p = 0.004), and to be more depressed postnatally (p = 0.0001).

CONCLUSION

Social support during pregnancy can be measured in a meaningful and simple way through the use of a short questionnaire administered at the prenatal booking-in visit.

Multiple copies of beta-lactoglobulin promoter do not function as LCR

Increasing the number of transcription factor binding sites within a construct can enhance expression. In an attempt to create a synthetic locus control region for mammary expression, we have generated beta-lactoglobulin-reporter constructs with multiple copies of the cluster of transcription sites normally located within the proximal promoter. These constructs were functionally tested by stable transfection of mammary epithelial cells in vitro and in transgenic mice in vivo. Rather than enhancing expression, multimerisation of the promoter region acted neither in vivo nor in vitro to enhance expression. Indeed, its presence reduced expression. This failure to enhance expression was reflected in the inability of this region to form a DNaseI hypersensitive site autonomously in mammary chromatin in vivo. It is implicit from our study that not all combinations of transcription factor binding sites will enhance transcription.